No one described the moral economy of wet nursing more eloquently than the Irish-born, British writer George Moore. In his 1894 novel Esther Waters, the heroine confronts a selfish employer who has denied her permission to visit her sick child and rages:

Moore's heroine, Esther Waters, articulated what physicians had long admitted – that wet nursing often involved trading the life of a poor baby for that of a rich one. Or, as one physician depicted it, “by the sacrifice of the infant of the poor woman, the offspring of the wealthy will be preserved.” Luther Emmett Holt, the preeminent pediatrician of the late nineteenth and early twentieth centuries, concurred. “Employment of wet-nurses tends, on the whole,” he wrote, “to increase infant mortality rather than reduce it, owing to the excessively high mortality rate of the wet-nurses' infants.”

The medical literature makes clear that doctors wrestled with the moral dimensions of wet nursing and, in some cases, tried to mitigate its impact.

The steady decline of wet nursing that began in the nineteenth century concluded in the twentieth century with the transformation of human milk into a commodity. In 1900 wet nurses occupied several small niches – suckling foundlings in institutions or working for well-to-do private families. By the 1910s and 1920s the number of wet nurses in these venues had decreased, although new opportunities arose for women willing to suckle abandoned babies in their homes or premature infants in hospitals. At the same time, a new career opened for lactating mothers: expressing and selling their breast milk for use in homes and hospitals. This procedure proved so successful that by the 1930s wet nurses had almost entirely vanished, replaced by bottled human milk. As one physician described it, human milk had become “therapeutic merchandise.”

In the case of human milk, commodification – the process by which things come to have economic value – was configured by the long history of wet nursing. Not surprisingly, traditional ideas about milk and character uncoupled slowly. The personal characteristics of wet nurses – their health, morals, willingness to obey authority, emotional ties to their own children – had long been crucial measures of their worth. So too were women who sold their milk judged by more than just the product that they made. In the end, however, commodification transformed the meaning of breast milk.

The task of locating healthy wet nurses remained a difficult one for late nineteenth- and early twentieth-century physicians, despite the development of institutions housing large numbers of new mothers. New York pediatrician Louis Fischer complained in his 1901 textbook, Infant-Feeding: In its Relation to Health and Disease, that there was no easy means for finding acceptable candidates. “As no licensed agencies, exist,” he wrote, “a few people having so-called influences procure wet-nurses by friendship, or something similar, from superintendents and house physicians where obstetrical work is done.” The procurers bedeviled Fischer by sometimes referring women with only “colostrum-milk” or, in one case, offering a seventeen-year-old who had given birth prematurely, “evidently an abortion,” and whose milk was “thin water.” Just as a previous generation had found itself at the mercy of the proprietors of intelligence offices and maternity home operators, early twentieth-century physicians believed themselves to be preyed upon by a new kind of entrepreneur, succinctly labeled by Fischer as “people who traffic in wet-nurses for a fee.”

Although Fischer's observations regarding the lack of a reliable system echo those of an earlier generation of physicians, his specific allegations suggest that doctors had more resources at hand than in previous decades. The “traffickers” Fischer wrote of mediated between hospital-based physicians and physicians who worked for private families. Their niche was made possible by the rise of obstetric facilities serving poor women, the development of hospital internships, and the growing expectation that physicians, not individual families, would inspect and hire wet nurses.

Bottled breast milk remains to this day a vital product for a small number of infants. However, it is collected and distributed far differently than it was early in the twentieth century. It is no longer a commodity sold by working-class women, but has become, instead, a gift. And it is given not in the expectation of reciprocity, but as part of a “moral transaction” encompassing late twentieth-century perceptions of infancy, mothering, economy, and society. The idea that an infant might die because its family lacks the means to purchase breast milk has become morally repugnant, just as has the notion that a woman might earn a living by selling her milk.

The transformed meaning of breast milk production is illustrated by an article in the December 1982 Boston Globe describing the meeting between Lacie Lynette Smith of Oklahoma and the women whose milk had kept her alive. Born with a rare allergic condition, Lacie could ingest nothing but breast milk. Her mother, unable to feed her because she was on medication, drained “every milk bank we could find.” On the verge of running out of milk, she contacted the milk bank of Worcester, Massachusetts – one of thirty operating milk banks in the United States, and one with 275 donors. The Worcester milk bank started sending Lacie the milk she needed, and at the age of nineteen months Lacie traveled to New England to meet her unseen benefactors.

In her autobiography, Blackberry Winter (1972), Margaret Mead recalled the impending birth of her first child. Clearly influenced by her field work in regions where neither bottles nor formulas were available, the eminent anthropologist wrote of how she promised herself that she would hire a wet nurse if she could not breast-feed her child.

Mead would have been hard pressed to hire a wet nurse in 1939, the year of her daughter's birth. Although hospitals sometimes kept women on call to provide breast milk to premature infants, wet nursing as a form of domestic service was fast becoming extinct. Women who could not or would not breast-feed their babies typically provided them with an artificial formula composed of modified cow's milk. Indeed, by the middle of the twentieth century, many American families routinely chose bottle-feeding over breast-feeding, perceiving the former to be the modern, scientific way to rear children. Mead thus was far out of step with her contemporaries. Her field work in less developed regions had taught her something most Americans preferred to forget: that human infants are most likely to survive and flourish when fed human milk.

There are only three ways to nourish an infant: with its own mother's milk, with an artificial food, or with the milk of a woman who is not its mother – a wet nurse. An obvious question is why Americans rejected wet nursing, assuming that what “science” produced was superior to what “nature” provided.

The decline of wet nursing in the late nineteenth century reflected advances in artificial feeding, shifting cultural beliefs regarding motherhood, and new employment opportunities for women previously hired as wet nurses. Artificial feeding became the first choice of many middle-class women, as Rima Apple has explained, not only because it was easier, safer, and cheaper than wet nursing but also because it was promoted and used in the context of the maternal ideology known as scientific motherhood.

As America industrialized, child rearing became a home industry for middle-class women. Even as the percentage of single women who participated in the labor force soared and the number of women professionals expanded in occupations such as teaching and nursing, motherhood continued to be judged women's most vital career. The cultural significance of motherhood gained strength from women's collective action. Female reform organizations stressed improving society to make a better world for children – an ideology that historians would call “domestic feminism.” The Women's Christian Temperance Union, founded in 1873 and one of the most visible and successful women's organizations of the nineteenth century, used the slogan “home protection” in its battle against the evils of alcohol. Other women's groups sailed in the same direction: making better children and better homes their collective destination. Among the largest organizations with this goal were the General Federation of Women's Clubs, an umbrella group organized in 1890, whose numerous constituent members engaged in programs of domestic welfare, and the National Congress of Mothers, which was founded in 1897 to support the education of mothers and to expand the relationship between the child and the state.

In 1881, physician Jerome Walker published a novel entitled The First Baby: His Trials and the Trials of His Parents, an account of one family's experiences in rearing a young infant. The book, an extended didactic discussion of a popular subject, was thinly disguised as fiction so that it could compete in a market crammed with advice literature. In one segment, the hero, Robert Matthews, accompanied by the faithful family physician, Dr. Lyons, undertakes an extensive journey in search of a wet nurse. The trip is only moderately successful, leading Lyons to lament the absence of a “systematic effort to furnish the persons most needing wet nurses with just the right kind of woman.”

Walker's novel accurately delineates the complexity of the urban wet nurse marketplace, in which public facilities, private entrepreneurs, and benevolent organizations vied to supply families with wet nurses. At the core of the expanding layers of wet nurse suppliers was a wet nurse labor force increasingly composed of poor, single mothers. These were not the “right kind of women” referred to by Dr. Lyons. However, as the novel's characters and real-life families recognized, the wet nurse population was shaped not by the demands of employers and the preferences of physicians, but by the conditions of life and labor for urban, working-class women.

The evolution of the marketplace between 1830 and 1900 reflected three separate, simultaneous trends, beginning with the commercialization of domestic service.

Women who refuse to suckle their infants are “dead while they live,” wrote Cotton Mather in 1710. The celebrated Puritan minister's sentiments fore-shadowed generations of “family advisers,” who praised mothers for breast-feeding and excoriated those who hired wet nurses. Yet social observers, including Mather, understood that families sometimes needed wet nurses – women who played a vital, indeed life-giving, role in the nursery. Mather himself retained a wet nurse for at least one of his fifteen children, and he kept his own former wet nurse on his charity list.

The breach between cultural prescription and biological need marked Mather's writings as well as his life. In the former, he articulated both the religious objections to wet nurses and the practical reasons for using them. Elizabeth in Her Holy Retirement (1710), written to “Prepare a Pious Woman for Her Lying In,” instructed mothers to suckle their own infants when possible and chided those who refused to do so: “be not such an ostrich as to decline it.” However, for those who tried and failed he had words of solace: “entertain it with submission to the will of God.” More pragmatic advice appeared in The Angel of Bethesda (1722), in which Mather summarized his knowledge of medicine, including the treatment of common illnesses and the promotion of health. In this volume, Mather suggested ways to increase the milk of either a wet nurse or a mother through the use of drugs and diet.

ALTERNATIVE MEANS OF PALLIATION

Despite so great an ordeal, Naples survived. The plan developed by the municipal giunta lay in ruins, but the city nevertheless weathered the crisis. Part of the explanation for this endurance was a feature of the disease itself – one of the great ‘cholera mysteries’ that characterize the history of this exotic pestilence. For reasons still insufficiently understood, epidemic cholera is self-limiting. Thus in Naples the epidemic began by rapidly and violently destroying those individuals who were most at risk. It then began slowly to subside after the catharsis of mid-September. The circle of its victims narrowed, and the rate of mortality declined. By the end of September it no longer appeared that the city was being inexorably annihilated. The medical crisis was slowly abating. In October the daily bills of mortality were almost comforting, so marked was the contrast with the preceding weeks. Figures that, in August, would have created panic, brought relief after the experience of September. Although the outburst continued into early November, the official daily number of deaths never again climbed as high as ninety. There began instead a slow descent into single digits.

Imperceptibly, tensions in the city followed the downward curve of mortality. With fewer cases a day, conflicts became less frequent, the hospital service improved, the cemetery kept pace with the smaller number of cadavers, and scenes of horror grew steadily rarer. Terror itself began to subside.

The Crosses – White and Red

The spontaneous decline of the epidemic force of the disease, however, is only one aspect of the gradual return to near-normality that occurred in October.

Neapolitan experience between 1884 and 1911 vindicates Asa Briggs and Louis Chevalier in their early insight that Asiatic cholera was a major transformative experience in the societies it affected, linking the history of medicine to the broader concerns of political, social, cultural and urban history. The ravages of the city of Naples in this period constitute an ideal test case for such a perspective because they occur so late. The fifth and sixth pandemics that mark the boundaries of this study were unlike the dramatic events of the 1830s that have most attracted historians. By the time the infection broke out in the boroughs of Porto and Mercato in the summer of 1884, it was an all too familiar visitor; its aetiology was largely understood; the mortality it caused had greatly diminished; and the medical and political authorities of the day understood the preventive measures that needed to be taken to prevent further epidemics. In 1910 and 1911 cholera could even be described as a disease whose time had passed because highly effective means existed to prevent, contain and treat it.

Even in such circumstances, cholera had a major impact on the history of the city. A major reason in 1884 is what might be termed its moral chronology. Morally, the epidemic of that year was the first for which the new Liberal regime could be held responsible. United Italy had already been devastated by a major epidemic of cholera in the 1860s. At that early date, however, the overthrow of the ancien régime was too recent and the new order too precariously established for it to be held accountable for the conditions that promoted Asiatic cholera.

PROLOGUE: THE INVASION OF APULIA

By the time of the renewed threat to Naples in 1910, the local and national authorities had long anticipated the return of Asiatic cholera. The sixth pandemic began its ravages in 1899 in Bengal. It then moved relentlessly westward along two established bacterial highways. To the north the disease followed the trade routes to the Punjab, Afghanistan and Persia. Crossing the Caspian Sea, it journeyed up the Volga to Moscow and the west. At the same time the cholera moved in a second, more southerly direction, travelling overland to Bombay and Madras; then by sea to Ceylon and Jeddah. It then accompanied the pilgrims to Mecca in 1902 and dispersed with them across the Red Sea to Egypt, the Middle East and North Africa.

The Department of Public Health in the Ministry of the Interior anxiously followed this westward movement and sounded the alarm in 1904, when cholera invaded the Russian Empire and developed into a full-scale epidemic. In the summer of 1905 the Ministry recorded outbreaks in Poland, Germany and the Hapsburg Empire, and observed that Italy was in clear danger. The authorities identified the Austrian border, Apulia and the ports of Naples and Genoa as particularly vulnerable. In September 1905 the Ministry of the Interior declared that Italy was now on a sanitary war-footing because the arrival of the disease on Italian soil was ‘not just probable, but imminent’.

As the Ministry had feared, the Vibrio cholerae reached Italy in the summer of 1910, claiming its first victims on the Adriatic coastline of Apulia that the authorities had identified as a locality of special risk.

With a population of nearly half a million people occupying an area of 8 square kilometers, Naples in 1884 was the largest city in Italy. A great Mediterranean seaport famous for evil smells and foul water, it provided perfect conditions for an epidemic of Asiatic cholera. So well known were the pernicious effects of even a visit to the city that in the final decades of the nineteenth century the Neapolitan economy suffered severely as frightened tourists avoided Naples entirely or made fleeting visits to the ancient sights, where they drank only wine and covered their noses. The press, complained Alderman Vincenzo Pizzuti in 1873, ‘writes of us as if we were semi-barbarian Africans’.

The city faced south onto the Bay of Naples, stretching for three miles in an arc along the coast. To the traveller arriving by sea, Naples rose above the harbour in the shape of an amphitheatre. The Lower City, built on land reclaimed from the Mediterranean, formed the stage. It was enclosed to the north and west by a semicircle of hills; to the east by swamps; and to the south by the waters of the Bay. The stage was divided into two unequal crescents by the spur of the Pizzofalcone hill. To the west stood the small and salubrious neighbourhood of Chiaia; to the east, the teeming slums of the Old City. The slopes of the encircling hills were graced by the elegant homes of the Upper City.

The medical histories of Upper and Lower Naples were sharply divergent, and it was common for local doctors to write of the great metropolis as consisting of two separate cities.